Placental Abruption

Archived User

Placental Abruption

I was diagnosed with placental abruption after already being on bedrest for PTL. I was originally on bedrest at 26 weeks, started spotting at 31 weeks. The spotting lasted  3 days. Previa was ruled out with u/s. Diagnosed with abruption because of tenderness, pain and, of course, the bleeding. I was told I would have to have a c-section around 37 weeks. How real is the danger of a vaginal birth with a partial abruption? I am on bedrest until I deliver, but I want to be able to deliver naturally. This is my second, and I had no problems with her. She was a natural delivery. Thanks!

Henci Goer

RE: Placental Abruption
(in response to Archived User)

There is no general answer to "how real is the danger?" It depends on the specifics of your case. I think the best way I could be helpful to you is to ask another of Lamaze's resident experts, who is a midwife, to give you an overview of the issues of partial abruption and suggest what questions to ask and options to discuss with your care providers.

-- Henci

Archived User

RE: Placental Abruption
(in response to Archived User)

I am a midwife and management of pregnancies complicated by abruption are outside of my scope of practice, however I am happy to share a little about the evidence and some common sense thoughts on having a safe and healthy birth. 

A review of the management and outcomes of placental abruption in the UptoDate database (a database of evidence-based reviews accessible by clinicians only) begins:

"Although the impact of placental abruption on pregnancy outcomes is fairly well-described, very few studies have examined the management of pregnancies complicated by abruption. Thus, guidelines regarding management of placental abruption are based on anecdotal experience, published literature, and good clinical sense."

These guidelines, which, again, are not necessarily based on good quality evidence, state that "Vaginal delivery is reasonable if the maternal status is stable and the fetal heart tracing is reassuring." The authors state that oxytocin and artificial rupture of the membranes can ensure that the baby is delivered "as quickly as possible" but I would argue strongly against the routine or liberal use of these measures, as they can put additional stress on an already stressed baby, resulting in injuries related to reduced oxygenation. They could also lead to ominous heart rate changes that could lead to cesarean section (necessary or otherwise).  The goal should not be a quick birth, but a safe birth and one that is as gentle as possible on the baby. Staying off your back in labor and using spontaneous pushing (following your own urge to push, rather than holding your breath for prolong periods which others coach you to push) are two ways to keep birth as gentle as possible and provide plenty of oxygen to your baby.

The guidelines stress, and I would certainly agree, that continuous electronic fetal monitoring and at least one intravenous line should be used. The risk of hemorrhage - both during labor or postpartum - is elevated, so the IV line can provide access to give fluids or blood products if necessary. The elevated risk of postpartum hemorrhage means that active management of this stage of labor (with oxytocin infusion and fundal massage to deliver the placenta) may be prudent. 

If you have ongoing major blood loss or there are signs that your baby is compromised, c-section is the safest route for giving birth.

I hope this information is helpful. Based on the UptoDate review, it does not seem that cesarean delivery at 37 weeks is necessary for every woman experiencing partial abruption, although the recommendation in your individual case may be different. It might be helpful for you to know your doctor's c-section rate. A rate around 15-20% would indicate that your doctor uses cesarean sparingly when real complications arise. A cesarean rate above 30% is a strong indicator that your obstetrician recommends cesarean frequently without looking at individual circumstances. You may need to change providers if you do not think your current provider will work with you to make a plan for the safest, healthiest birth possible.

Even if you plan for a vaginal birth, your risk of needing a cesarean is certainly increased. You may want to find a support group online of other mothers or a good childbirth educator or doula who can help you clarify your birth plan and priorities if a cesarean becomes necessary. Such a support group can also help you handle the emotional and physical toll of life on bedrest.

 

 

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